Dr John Middleton, Director of Public Health for Sandwell and FPH Vice President, email vpPolicy@fph.org.uk

On first reading, the health bill seems silent on public health roles in the health service. More than 300 public health specialists and consultants who work in health service public health are justifiably nervous about what the future public health system holds for them. In a set of reforms establishing Public Health England and local-authority-based public health directors, they could have expected some acknowledgement. There is what we expected about the other two domains of public health: health protection and health improvement.

Fortunately the subtext of the bill holds much more hope for public health in health services. It confers duties of engagement, partnership, quality and reducing inequalities on the NHS Commissioning Board and GP commissioners. Even Monitor needs public health – if it is to create national tariffs that genuinely reflect the most effective interventions delivered most efficiently rather than reward incompetence, gaming and worsening of inequalities in health services.

Health-services-related public health is arguably the most technically exacting facet of public health and certainly the most contentious. It requires rigorous knowledge of healthcare interventions and epidemiological and interpretative skills are needed to show what works and what does harm. As the margins of benefit from new drugs and treatments get smaller, careful analysis becomes ever more necessary. Assessing complex healthcare data is crucial activity – truly a matter of life and death – not an exercise of faceless bureaucracy or unnecessary management cost. Some patients will die when we do decide to fund their high cost – and high risk – drug.

These funding decisions cannot be left to the newly emasculated NICE – implementation is local. The best national policies flounder if they are not locally understood and implemented.

Health services public health is not always popular – rationing decisions invariably get unravelled in appeals, press examination, in legal dispute and judicial review. There may be political expectation that big healthcare private organisations will bring the skills to evaluate healthcare for GP commissioners in the future. This has hardly been borne out by the hospital deaths misinformation, or the quasi-scientific risk-stratification products on offer.

The return of public health to local authorities holds the welcome recognition of where the major influences on health still are. Many of us cite McKeown’s decline of mortality since 1840 due to clean water, sanitation, better housing and working conditions, better nutrition and smaller family size. The big environmental challenges, work with social care on reablement and personalisation, and the need to reduce health inequalities are live issues for public health in local authorities. Twenty-first century diseases such as obesity, relationship and behavioural problems and addictions also lend themselves to big public health responses from a local-authority base. But equally relevant in the 21st century is the health service contribution to life expectancy gain – Bunker, Frasier and Mostellar’s Millbank review concluded that about 30% of the life-expectancy improvement since the NHS came along was due to healthcare factors. The capacity for health services to do harm as well as good is immense, and the need to get better value for money in healthcare is ever more relevant.

There is growing recognition of the need for health promotion or ‘lifestyle’ interventions in healthcare. Acute services are seeing it as part of QUIPP and many are instigating ‘stop before the op’ smoking cessation programmes. GPs also increasingly have opportunities to refer to food and fitness services, psychological therapies and addiction-brief interventions. It is easy to see how GP commissioning should be involved in commissioning alcohol services – jointly with the local authority DsPH – to cover all preventive and therapeutic interventions. Less easy, but just as relevant in reducing hospital dependency, would be joint commissions on fit-for-work programmes, welfare rights and housing improvement.

With hospitals being more dangerous places than roads these days, health systems need public health skills more than ever. More than 30 consultants and specialists in public health work in acute hospital trusts. Hospitals, and health centres, are outlets for health information, signposts and venues for health promoting activity and potential exemplars of health improvement for staff, patients and visitors. Business choices for hospital and community trusts should be informed by good health-needs analysis, assessment of best evidence of effectiveness and evaluation. Care pathways should all include ‘lifestyle’ programmes as a key choice in the pathway– for example, before bariatric or vascular surgery. This is equally relevant in GP commissioning. For the first time we are beginning to have good data about morbidity and about quality of care in general practice. These data have to inform the joint strategic needs assessments. But they also have to be interpreted and used in primary care.

Public health specialists need to be embedded in organisations because that is the only way their advice will be taken on – consultancies we all take or leave. There should be consultant level public health expertise in all arms of the new health system – including the NHS Commissioning Board and Monitor. But we need also a coherent base on which all the public health training and development is founded – only Public Health England appears capable of that. There are encouraging signs that GPs and others in the new NHS are recognising the need for healthcare public health – you won’t find it in the health bill.

Health Secretary Andrew Lansley wants to encourage people to eat healthily, drink sensibly, stop smoking and get more active without lecturing or hectoring them. People don’t like being told what to do or not do – least of all by the Government – so Lansley says we should provide them with information and incentives and let them choose for themselves – nudging rather than nannying. Hence the Great Change4Life Swapathon with its supermarket discount vouchers for healthy options. Lots of carrots, no sticks.

There’s also much nudging behind Lansley’s Responsibility Deal with the food, drink and fitness industries. Double nudging – Lansley nudging them to nudge the public. Industry will “pledge” to provide information and incentives encouraging healthier choices.

So where’s the fudge? In return for industry cooperation (and cash) Lansley has said he’ll go easy on mandatory regulations around such things as marketing, labelling, availability and pricing. To be fair, he doesn’t rule these threats out completely. He talks about the Nuffield Ladder of Interventions, with the least intrusive (information, education and incentives) at the bottom and the most intrusive (regulation and legislation) at the top. But he’s made it clear he doesn’t want to climb that ladder unless he absolutely has to. It wouldn’t fit his political philosophy.

So there’s a big fudge around how he’ll monitor adherence to voluntary approaches, assess progress and judge when to bring in mandatory controls. The food and drink industries are notoriously slippery, evasive and foot-dragging – just look at labelling and marketing. Meanwhile the health lobby is going along with the Responsibility Deal in the hope that things might be different this time – well aware they risk being be-smudged as part of the fudge.

I’d like to see a solid pledge by the Government to regulate or legislate if voluntary approaches fail and to be crystal clear about how and when such judgements will be made. Without an explicit commitment to use force if necessary, the deal will be seen as no more than a charade letting Big Business off the hook.

In sultry heat, I join a continuous stream of people making their laborious way up the 392 steps to the mausoleum of Dr Sun Yat-sen. It’s beautifully situated on the slope of a wooded mountainside in a huge park in Nanjing, Eastern China.

Everyone is in holiday mood, stopping frequently to rest, drink and take snaps of each other against the backdrop of the splendid double-eaved sacrificial hall built a few years after Dr Sun’s death in 1925.

But as soon as they reach the sarcophagus, absolute silence descends in an atmosphere of deep awe and respect. Dr Sun is a much revered figure, considered to be the ‘Father of the Republic of China,’ honoured by Chinese people on both sides of the Taiwan Strait.

He qualified in medicine at the turn of the century, but soon gave up medicine for politics, plotting the overthrow of the Qing Emperor and helping to establish the fledgling republic. As its inaugural President he extolled three fundamental ‘Principles of the People’ inspired by Abraham Lincoln: One nation of the people – governed by the power of the people – for the welfare of the people.

Back at the conference I’m attending on public health in Asia and the Pacific Rim by the APRU World Institute, I think about the parallels between Dr Sun’s three principles and Michael Marmot’s basic tenets of a healthy society – one that upholds fairness, social justice and the pursuit of wellbeing.

Certainly, health inequalities is a recurring theme at the conference. There are huge disparities between the rich and the poor across the region – and between the cities and rural areas – and this is reflected in the disease patterns observed.

The conference theme is the epidemic of chronic, non-communicable diseases (NCDs) in the tiger economies of east Asia. This part of the world is now going through the escalation of cardiovascular disease we saw in the West about 40 years ago.

But it’s happening so fast here. Urbanisation is rampant – by 2020 China will have over 200 cities each boasting more than a million population. And this is coupled with globalisation, code for westernisation. Nearly every major city has its MacDonalds, KFC and Pizza Hut. Smoking is on a roll – mostly western brands – and in many Asia-Pacific countries, notably China, it’s still allowed in public places.

As to physical activity, whilst it’s true that cycling is still a common means of transport – here in Nanjing for example there are dozens of pushbikes bunched together at the front of the traffic at every stoplight – nevertheless people are increasingly switching to scooters or cars. Air pollution is a big problem in China – not good for the lungs, especially if you’re on a bike. All in all, there can be little surprise that obesity, diabetes, stroke, coronary heart disease, lung cancer and chronic obstructive pulmonary disease rates are rocketing right across the region.

What’s more, although these health problems were first seen most among the better-off – the early adopters of western lifestyles – in recent years the problems have begun to extend down the social gradient, particularly among the urban poor.

Effective prevention and early diagnosis are clearly crucial – yet many Asia-Pacific countries have health systems skewed to favour hospital and specialist services, with little or no investment in health promotion or primary care. Although China for example has well developed communicable disease prevention and control systems, its approach to non-communicable disease is much less robust and its primary care is largely based on private specialists and a vast unregulated army of traditional medicine practitioners.

This pattern is typical of the whole region, and poorer people thus face the double whammy of unhealthy lifestyles plus inadequate access to preventive, diagnostic or curative care. So, despite the best efforts of policymakers to reduce health inequalities in many of the emerging tiger economies of the Asia Pacific, the headlong rush to the cities has meant that the cards are truly stacked against the less well-off.

As in the West, it will take a multisectoral mix of interventions to halt the rising tide of NCDs in these countries – health education, social marketing, regulation of the food and tobacco industries and, above all, health systems change. Marmot argues that efforts should be applied across the social gradient. But from the workers’ high-rises of China’s cities to the slums of Mumbai and the favelas of Rio, there’s also a clear need to focus on the world’s urban poor.

As the conference closes I think again of Dr Sun Yat-sen. I’m sure that, as a medical man, democrat and visionary, he would wish to see public health of the people, by the people, for the people, applied fairly to all the people, not just those who can afford to pay.

The Faculty of Public Health today publishes our joint manifesto on public health, alongside the Royal Society of Public Health. 12 Steps to Better Public Health offers a dozen practical recommendations that, if adopted by the next government, will improve the UK’s health and well-being for the new decade.

The joint public health manifesto calls for:

A minimum price of 50p per unit of alcohol sold

No junk food advertising in pre-watershed television

Ban smoking in cars with children

Chlamydia screening for university and college freshers

20 mph limit in built up areas

A dedicated school nurse for every secondary school

25% increase in cycle lanes and cycle racks by 2015

Compulsory and standardised front-of-pack labelling for all pre-packaged food

Olympic legacy to include commitment to expand and upgrade school sports facilities and playing fields across the UK

Introduce presumed consent for organ donation

Free school meals for all children under 16

Stop the use of transfats

The full manifesto is available to read here, and the front-page Guardian story, with an accompanying podcast from our President Alan Maryon-Davis, is available to read here.

I’m somewhere over the steppes of Central Asia – on my way back from an international conference in Hong Kong on the theme of emerging issues in public health. Time to sit back and reflect.

It was a good conference – attracting delegates from all over East Asia and beyond. Inevitably, much of the focus was on the ever-increasing burden of chronic disease in this rapidly developing and urbanising region – not just China and India, but Vietnam, Cambodia, Thailand, Malaysia and even Burma.

The same pattern is repeated again and again. People flock to the cities to find work, the buildings zoom up, the traffic multiplies, the diet westernises and the waistbands expand. Obesity linked to diabetes linked to heart disease and stroke. Not helped by the efforts of the tobacco industry. As a result, the health systems, mostly private sector, creak and buckle. There’s widespread recognition that public health improvement and primary care are vital – but also widespread concern that they are chronically underfunded, patchily organised and poorly linked together.

One key to this is education – linking public health and clinical training -, a recurring theme of the conference and the main thrust of my keynote presentation.

But the real value in my travelling to Hong Kong was undoubtedly in the face-to-face meetings with people who have the power and influence to build up public health and primary care and link them together. There is no substitute for the personal touch in this part of the world – perhaps in any part of the world. Tele-meetings, invaluable though they are for many purposes, simply don’t cut it for forming close working relationships and building camaraderie and trust. Business people know this – to clinch a deal you need to get to know each other.

But, as I fly back across Mongolia and Siberia towards Moscow, St Petersburg and the Baltic, Copenhagen edges into my moving map and gnaws at my conscience. I know that this kind of meeting will have to become a rarity – at least for me. I do not want to be a climate criminal. I do not want to let the planet down. Of course I only fly long-haul to meetings where I feel my being there might make a real difference. But even so, I am determined to be much more selective in future. And I’m sure many others will be making the same resolution.

Yes, it poses awful dilemmas – can I really accept this next invitation to another faraway place? But it’s a nettle the academic world, and the business world, will increasingly have to grasp.

Otherwise Heathrow will need a third runway – and we’ll all need another Earth.

Our economy is geared towards making us sick, according to speakers at the Big Food Debate in Liverpool. The roots lie in the war and post-war years when the population was urged to eat more meat, butter and sugar and the farming industry was supported to grow, grow and grow.

Academics in nutrition, public health and food industry professionals met here to discuss what was wrong with our current food production and consumption.

There have been two major messages to take away.

Robin Ireland, Heart of Mersey chief executive argued that food campaigners have to learn from the anti-smoking lobby and push for national reforms like the smoke-free legislation or the vote last week to ban point-of-sale displays and vending machines.

Professor Philip James, International Obesity Task Force Chair, felt obesity was akin to climate change. Responsibility could not be put on the individual alone, that was just not enough anymore. We needed to change our toxic environment – food chain, transport infrastructure, urban design, animal and agriculture industry – through wholesale strategic measures.

We clearly need to create a new food chain that benefits people, not just the food industry. Too much to ask? Not really, according to Professor Simon Capewell (Professor of Clinical Epidemiology at Liverpool University and Chair of FPH Cardiovascular Committee) who pointed out that the UK is lagging behind other countries and asked why we cannot use legislation to ban the stuff in our food that’s making us so sick – trans fats, salt and saturated fats. However, Professor Jack Winkler (Director of Nutrition Policy Unit at London Metropolitan University) argued for incremental changes. He called the FSA’s salt reduction policy the single most successful nutrition policy since the Second World War, exactly because it has been so unobstrusive and incremental. Professor Philip James said it was necessary to work with the food industry because they had the power to transform the food we choose to eat

Whatever the view, more must be done or we have a very real obesity epidemic in our hands; not to mention climate chaos because the way in which food is produced and consumed is inextricably linked with the environment.

Amidst the doom and gloom were positive examples: take the Netherlands which has redesigned its cities to enable easy cycling and walking, transforming the health profile of its population. In the Caribbean, obesity (and public health) is recognised as a cross-government responsibility, not just one for the health ministry.

But some englightened initiatives were to be found closer to home. Last night at a lovely Italian restaurant in Liverpool’s Albert Dock, we were amazed to find a healthy eating guide attached to the menu, showing the dishes that are good energy boosters, the ones perfect for your daily dose of vitamins and so on. And this morning, at our hotel, there was a menu card explaining the ‘superfood’ options available at the breakfast buffet. We’d certainly never seen anything like it in London (apart from in an organic juice cafe perhaps…).

But as it stands, we’re eating ourselves sick and while we’re at it, devouring the health of the planet as well.

Here I am, enjoying a little summer frivolity up at the Edinburgh Fringe, and it seems to me there isn’t a stand-up standing who hasn’t made some play with swine flu or obesity or the crack-down on binge drinking. From Rhod Gilbert to Rich Hall, from Jason Byrne to Stewart Lee, they’ve all had a go at public health one way or another.

Meanwhile quite a few of the musical cabarets are getting in on the act too. The Oompah Band are sending up the credit crunch with lots of brassy references to redundancy, repossessed homes and the horrors of being down-and-out. Fascinating Aida do a hilarious song about health and safety on children’s outings and a wonderful calypso about the impact of climate change in the Shetlands. And yes, the comedy group I’m singing in, Instant Sunshine, can’t resist joining in with a number about the perils of the demon drink.

But what a strange time I’m having. One minute I’m talking seriously on the radio, down the line from the BBC’s Edinburgh studio, about ham sandwiches, candle wax and the risk of cancer, and the next I’m up on stage singing a silly song about a showjumper who’s lost his horse. One minute I’m on Sky News debating the joys of the NHS versus the inequities of the US healthcare system, and the next I’m impersonating the Queen opening a desperately unfinished Olympic site in 2012.

But hey, that’s showbiz for you. Instant Sunshine’s stuff is gently humorous, utterly inoffensive and, let’s face it, a little dated. We first came here in 1975 and have been back every other year since, thanks to a small but faithful following. There have been thousands of acts on the Fringe, but we are probably the longest-serving. Certainly our queue has by far the most zimmer frames.

It’s all great fun and utterly frivolous. And I suppose, if it makes people happy for a while, it’s public health – kind of – isn’t it?

Disclaimer

The aim of this blog is to encourage discussion and debate on public health issues. The views expressed here are the personal views of authors, and the content does not reflect the official position of the Faculty of Public Health. However, discussion generated here may be used to influence the development of organisational policy.